4Using PPE: Individual and Institutional Issues

Personal protective equipment (PPE) is one of the vital components of a system of safety controls and preventive measures used in healthcare facilities. The recent heightened awareness of patient safety issues has opened up opportunities to improve worker safety with the potential to benefit workers, patients, family members, and others who interact in the healthcare setting.

Because PPE works by acting as a barrier to hazardous agents, healthcare workers face challenges in wearing PPE that include difficulties in verbal communications and interactions with patients and family members, maintaining tactile sensitivity through gloves, and physiological burdens such as difficulties in breathing due to respirators. For healthcare workers this may affect their work and the quality of interpersonal relationships with patients and family members. As manufacturers continue to develop PPE that can reduce the job-related constraints, healthcare institutions and individual healthcare workers need to improve their adherence to appropriate PPE use. Healthcare employers need to provide a work environment that values worker safety, including provision of PPE that is effective against the hazards faced in the healthcare workplace. In turn, healthcare workers need to take responsibility to properly use PPE, and managers should ensure that the staff members they supervise also make proper use of PPE.

This chapter focuses on ensuring appropriate use of PPE in the healthcare workplace and maintaining worker safety as one of the highest priorities in the healthcare organization. Healthcare workers are a heterogeneous group with a range of skills from administrative to clinical expertise (see Chapter 1). As has been demonstrated with seasonal influenza, an influenza pandemic will bring a variety of potential expo-

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4
Using PPE: Individual and Institutional Issues
Personal protective equipment (PPE) is one of the vital components
of a system of safety controls and preventive measures used in healthcare
facilities. The recent heightened awareness of patient safety issues has
opened up opportunities to improve worker safety with the potential to
benefit workers, patients, family members, and others who interact in the
healthcare setting.
Because PPE works by acting as a barrier to hazardous agents,
healthcare workers face challenges in wearing PPE that include difficul-
ties in verbal communications and interactions with patients and family
members, maintaining tactile sensitivity through gloves, and physiologi-
cal burdens such as difficulties in breathing due to respirators. For
healthcare workers this may affect their work and the quality of interper-
sonal relationships with patients and family members. As manufacturers
continue to develop PPE that can reduce the job-related constraints,
healthcare institutions and individual healthcare workers need to improve
their adherence to appropriate PPE use. Healthcare employers need to
provide a work environment that values worker safety, including provi-
sion of PPE that is effective against the hazards faced in the healthcare
workplace. In turn, healthcare workers need to take responsibility to
properly use PPE, and managers should ensure that the staff members
they supervise also make proper use of PPE.
This chapter focuses on ensuring appropriate use of PPE in the
healthcare workplace and maintaining worker safety as one of the highest
priorities in the healthcare organization. Healthcare workers are a hetero-
geneous group with a range of skills from administrative to clinical ex-
pertise (see Chapter 1). As has been demonstrated with seasonal
influenza, an influenza pandemic will bring a variety of potential expo-
113

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114 PREPARING FOR AN INFLUENZA PANDEMIC
sure scenarios with the potential for long work hours, high patient loads,
and profound physical and emotional stress. The current limited surge
capacity of emergency departments and healthcare facilities will be over-
stretched. Infection control knowledge and capacity will thus need to be
fostered throughout the organization so that as many personnel as possi-
ble will have immediate knowledge that they can impart to emergency
responders, temporary workers, and volunteers who may be actively in-
volved in emergency care. Although this chapter can not explore all of
the specific issues, it is hoped that the strategies presented can be used in
tailoring future efforts to improve worker safety.
The chapter begins with an overview of studies regarding PPE use by
healthcare workers and the context of PPE use in the healthcare setting.
Four strategies for improving worker safety are then discussed in detail
with a focus on collaborative efforts and commitments by employers and
healthcare workers to: provide leadership and commitment to worker
safety, emphasize education and training, improve feedback and en-
forcement, and clarify relevant work practices.
USING PPE: IDENTIFYING THE CHALLENGES
Despite expert recommendations and high-risk conditions, healthcare
workers exhibit low rates of PPE use (Hammond et al., 1990; Kelen et
al., 1990; Afif et al., 2002). Although the use of PPE is often examined
by observational studies or survey questionnaires of individual workers,
assessments of the explanations for noncompliance and the solutions to
these issues need to focus beyond the individual and address the institu-
tional issues that prevent, allow, or even favor noncompliance.
Studies on this issue have focused on adherence to standard precau-
tions1 and few studies have examined interventions to improve adherence
rates. Although the knowledge base on compliance with standard precau-
tions is not extensive, pandemic influenza will likely present even further
complications.
Madan and colleagues (2001) observed emergency department per-
sonnel in a New Orleans hospital and recorded an overall compliance
rate of 38 percent with the application of barrier precautions. Of the 104
nurses and physicians studied, 41 percent used protective gowns, while
1
The report uses the broader term standard precautions (see Chapter 1), except in de-
scribing research in which the authors specifically use the term universal precautions.

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INDIVIDUAL AND INSTITUTIONAL ISSUES
only 10 percent wore masks2 and eye protection approved by the Occu-
pational Safety and Health Administration (OSHA). The lack of adher-
ence to appropriate use of respirators and protective eyewear is
especially prevalent throughout the literature; on the other hand, health-
care workers frequently wear gloves, with adherence often well above 90
percent (Helfgott et al., 1998; Evanoff et al., 1999). However, rates of
adherence to hand hygiene best practices are often low; for example, in
an observational study, Pittet and colleagues (2004) found 57 percent
overall adherence to hand hygiene protocols among 163 physicians.
Given the poor use of PPE, particularly respiratory PPE, and the high
risk of exposure of healthcare workers to bloodborne and airborne patho-
gens and other hazardous materials, it is crucial to use the data described
below and in Table 4-1 to develop and implement strategies to improve
the rates of adherence to PPE protocols and to mitigate risk.
Table 4-1 provides examples of studies that examined the use of PPE
and summarizes the barriers identified by healthcare workers when asked
why they did not use the proper equipment in situations where use was
appropriate. Lack of time is the most common reason healthcare workers
give for not adhering to safety regulations. Kelen and colleagues (1990)
note the time constraint barrier is consistent with their finding that much
lower levels of compliance were observed when immediate medical at-
tention was needed. Job hindrance, or the perception that using PPE in-
terferes with healthcare workers’ ability to perform their jobs, has also
been cited as a major reason for noncompliance (Kelen et al., 1990;
Willy et al., 1990; DeJoy et al., 1995). Nickell and colleagues (2004)
conducted a study in a Toronto hospital during the outbreak of severe
acute respiratory syndrome (SARS) in 2003 and found that wearing a
mask was cited as the most bothersome precaution for doctors and
nurses. Physical discomfort (92.9 percent), difficulty communicating
(47.0 percent), difficulty recognizing people (23.9 percent), and a sense
of isolation (13.0 percent) were the reasons given by the respondents
who had concerns about wearing masks. Focus groups of health profes-
sionals who wore PPE for extended periods of time during the SARS
outbreaks noted, “The masks weren’t very comfortable. . . . Obviously,
2
In discussing the literature on respiratory protection, this report uses the terminology
(masks or respirators) used by the investigators or authors of the cited journal article or
report. In some cases, it is not possible to determine whether the authors’ use of the term
masks refers to medical masks, respirators, or both.

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INDIVIDUAL AND INSTITUTIONAL ISSUES
Reasons Reported in the
Study Population Overview of Results Study for Noncompliance
Afif et al., Healthcare work- Of the 488 healthcare Noncompliance data not
2002 ers and visitors workers and visitors collected
observed at a observed, the average
university health rate of total compli-
center in ance with the methi-
Montreal cillin-resistant
Staphylococcus
aureus precautions
was 28%. Compli-
ance with glove and
gown precautions,
65%; hand hygiene,
35%
Nickell et al., Hospital employ- Survey focused on Reasons given by those
2004 ees working dur- psychosocial effects who reported that the
ing the SARS of SARS on hospital mask was bothersome:
outbreak in staff was returned by 92.9 % Physical discom-
Toronto 2,001 hospital em- fort
ployees. Masks were 47.0% Difficulty
reported by 70.2% of communicating
the workers as the 23.9% Difficulty recog-
most bothersome nizing people
SARS-related pre- 13.0% Sense of isolation
cautionary measure
Sadoh et al., Healthcare work- 433 healthcare work- Noncompliance data not
2006 ers selected from ers stated how often collected
multiple facilities they used gloves,
in Nigeria and aprons, and gowns
responding to an during surgery and
interviewer- deliveries:
administered never (16.5%); occa-
questionnaire sionally (19.7%);
always (63.8%). For
protective eyewear:
never (56.5%);
occasionally (27.2%);
always (16.3%)
NOTE: The terms (masks, surgical masks, respirators) used in this table are those used by the inves-
tigators or authors of the cited journal article or report. In some cases, it is not possible to determine
whether the authors use the term masks to refer to medical masks, respirators, or both.
a
The report uses the broader term standard precautions (see Chapter 1), except in describing re-
search in which the authors specifically use the term universal precautions.

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120 PREPARING FOR AN INFLUENZA PANDEMIC
everybody found the respirators, in particular, cramped or irritating too.
You sweat with them, so that’s going to affect the compliance. . . . There
were some [that were] very strange in their function and they looked
funny and they felt funny and they smelt funny” (Yassi et al., 2004, p.
64). For PPE to be used in the consistent manner necessary in the event
of pandemic influenza, healthcare workers must feel comfortable wear-
ing the equipment while retaining the ability to adequately communicate
with and effectively relate to their patients.
PPE compliance has also been found to be inversely proportional to
the amount of experience of the healthcare workers, and as discussed
later in this chapter, physicians are often less compliant with PPE than
nurses, students, and support staff. Helfgott and colleagues (1998) found
that rates of PPE use decreased each year from first- to fourth-year resi-
dents, while Gershon and colleagues (1995) reported that hospital work-
ers with fewer than 16 years of education complied more than those who
had additional years of educational experience. Researchers are unsure of
the reason behind this trend but have suggested a feeling of increased
invulnerability as a possible explanation (Moore et al., 2005a). It is im-
portant for physicians and senior staff to comply with safety regulations,
not only to protect themselves, but also to serve as a model for other staff
members.
FRAMEWORK FOR A CULTURE OF SAFETY
Improving worker safety necessitates an organization-wide dedica-
tion to the creation, implementation, evaluation, and maintenance of ef-
fective and current safety practices—a culture of safety. An organization
that has a functional and healthy safety culture is one in which all em-
ployees show a concern for safety issues within the infrastructure and act
to maintain or update safety standards. Further, the organizational com-
mitment to safety is evidenced by the organization’s policies, procedures,
management support, and resources dedicated to safety, which include
access to effective, appropriate, and state-of-the-art safety equipment. An

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INDIVIDUAL AND INSTITUTIONAL ISSUES
institutional commitment to a culture of safety3 establishes systems, poli-
cies, and practices to ensure that safety is the highest priority of the or-
ganization. If need be, productivity or efficiency are willingly sacrificed
in order to maintain safety (ECRI, 2005). This prioritization of safety has
been carefully examined in industries, such as chemical and power
plants, with a focus on achieving high-reliability organizations based on
safety factors at the individual level (e.g., attitudes and training), micro-
organizational level (e.g., management support, safety representatives,
accountability), and macroorganizational level (e.g., communication,
organization of technology and work processes, workforce specializa-
tion) (Hofmann et al., 1995). A positive work safety culture has been
described as a just culture, a learning culture, a reporting culture, and a
flexible culture (Reason, 1997).
In the healthcare setting, a strong culture of safety has been shown to
result in a higher rate of adherence to standard infection control precau-
tions among employees, a decreased incidence of exposure mishaps in
hospitals, and fewer workplace injuries among employees (Gershon et
al., 1995, 2000). As noted in Chapter 1, standard and transmission-based
precautions have been detailed by the Centers for Disease Control and
Prevention. The infectious characteristics of the particular strain of influ-
enza resulting in a pandemic will not be fully known until after the pan-
demic emerges. Consequently, infection control plans should be
adaptable to the current knowledge of transmission and altered as addi-
tional information becomes available.
Legal responsibility for employee PPE usage and adherence falls
upon the employer. For example, OSHA standards and regulations re-
garding respiratory protection state that the employer is responsible for
designing and implementing a respiratory protection program, monitor-
ing and evaluating program effectiveness, and maintaining proper
records regarding the program. Employers are also responsible for select-
ing the appropriate type of National Institute for Occupational Safety
and Health (NIOSH)-certified respirators, making them available to
employees at no charge, fit testing, cleaning, and storing them. Further,
3
Most of the empirical data discussed in the chapter involves measures that meet the
definition of safety climate rather than safety culture. The term safety climate is also of-
ten used in studies on this issue to refer to workers’ perceptions of the importance of
safety in their organization (Zohar, 1980). Safety climate has generally been measured by
asking workers how they rate their organization’s commitment to safety and has been
positively correlated with fewer occupational injuries and good safety performance in
hospitals and in non-healthcare settings (Cohen and Cleveland, 1983; Isla Diaz and Diaz
Cabrera, 1997; Gershon et al., 2000).

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OSHA regulations specify that it is the employer’s responsibility “to
establish and implement procedures for the proper use of respirators.
These requirements include prohibiting conditions that may result
in facepiece seal leakage, preventing employees from removing
respirators in hazardous environments [and] taking actions to ensure
continued effective respirator operation throughout the work shift”
(29 CFR 1910.134[g]).
In order to establish an effective culture of safety, responsibility for
both personal safety and the safety of others should be a joint employer-
employee responsibility. Although much of the responsibility for creat-
ing and monitoring a safety program is managerial, staff members should
be responsible for applying the safety practices to their work environ-
ment. It will be important for management, professional associations,
labor organizations, and others to emphasize the shared responsibilities
and stress the goal of improving worker safety. Although a more in-depth
discussion of organizational safety culture is beyond the scope of this
chapter, the references provided throughout the chapter are resources for
further discussion of the concepts and approaches.
Ensuring the Continuum of Safety Controls
The use of PPE is only one component of instilling and promoting a
safety culture in a healthcare institution. For example, during the SARS
outbreaks in 2003, changes implemented to ensure patient and worker
safety included quarantine, temperature checks on hospital employees,
restricting visitors, and hospital closures (Yassi et al., 2004).
As described in Chapter 1, the continuum of infection prevention and
safety controls includes environmental and engineering controls (e.g.,
number of air exchanges, availability of isolation rooms with negative
pressure ventilation) and administrative or work practice controls (e.g.,
protocols to ensure early disease recognition, vaccination policies, dis-
ease surveillance, infection control guidelines for patients and visitors,
decontamination of healthcare equipment and patient care rooms, risk
assessment education programs for healthcare workers) (Thorne et al.,
2004). The hierarchy of controls is meant to address hazards through di-
rect control at the source of the infection and along the path between the
infectious source and the employee. PPE is implemented at the individ-
ual level and is one component of effective infection prevention and con-
trol measures that particularly emphasize hand hygiene as a critical

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INDIVIDUAL AND INSTITUTIONAL ISSUES
action for reducing disease transmission. When all of these measures are
integrated and implemented, a continuum of safety exists; deploying
evidence-based improvements at any level can enhance the safety cul-
ture. DeJoy and colleagues (1996) examined approaches to minimizing
the risk from bloodborne pathogens that emphasized a work-systems ap-
proach integrating individual, job or task, and organizational or environ-
mental factors.
Factors Underlying Safety Culture in Healthcare Facilities
Much of the analysis of the safety cultures in healthcare organiza-
tions has focused on controlling the risk of bloodborne pathogens. A fac-
tor analysis of the results of a survey of 789 healthcare workers identified
six organizational factors underlying the hospital safety climate: senior
management support for safety programs; absence of workplace barriers
to safe work practices; cleanliness and orderliness of the worksite; mini-
mal conflict and good communications among staff; frequent safety-
related feedback and training by supervisors; and availability of PPE and
engineering controls (Gershon et al., 2000). Three of these factors—
senior management support, absence of workplace barriers, and cleanli-
ness or orderliness—were significantly associated with adherence to safe
work practices. In examining the individual and institutional factors re-
ported by nurses to be associated with their compliance with PPE rele-
vant to bloodborne pathogens, DeJoy and colleagues (2000) found that
ready availability of PPE predicted increased compliance with its use as
did receiving informal feedback on safety performance. A tool currently
used to assess the culture of safety in hospitals with regard to exposure to
bloodborne pathogens could be expanded to other routes of exposure
(Anderson et al., 2000; Gershon et al., 2000).
Few studies have specifically examined the individual, environ-
mental, and institutional factors related to PPE use in the healthcare
workplace. The most extensive recent effort was conducted by the Occu-
pational Health and Safety Agency for Healthcare in British Columbia,
which reviewed the literature on the use of PPE by healthcare workers
and conducted a set of 15 focus groups with healthcare workers in Ot-
tawa, Toronto, and Vancouver (Yassi et al., 2004, 2005; Moore et al.,
2005b). The literature review identified organizational, environmental,
and individual factors (Figure 4-1) that impact PPE-related behaviors and
adherence among healthcare workers. The 105 focus group participants

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136 PREPARING FOR AN INFLUENZA PANDEMIC
ate PPE use and proper procedures in donning and doffing PPE gear.
This approach is used in other work environments. For example, standard
practice in surgical operating rooms is for one nurse to be designated
with the explicit responsibility of ensuring a sterile work environment
and proper use of PPE. Similarly, before entering the scene of a fire, fire-
fighters must receive clearance from a supervisor that they have donned
all the proper equipment. A less invasive approach would be a require-
ment for staff to complete an adherence checklist, on which they would
note the protocols and PPE used. Responsibility for completing the ad-
herence checklist could be on an individual basis or used in conjunction
with the buddy system. Since the step-by-step process to avoid contami-
nation in doffing the equipment can be quite complex, a buddy system
might include going through the checklist together and completing the
adherence forms. Use of staff members as PPE champions is another
option. Staff workers well trained in PPE issues and behaviors could
identify both facilitators and barriers to use of PPE, as well as serving
as the lead in working with other staff to develop adherence and en-
forcement policies. Another avenue for promoting PPE use would be
patient-based reminders, which could serve as an adjunct to other moni-
toring systems. Patients would be encouraged and informed about speak-
ing up to ask workers to put on respirators, wash their hands, put on
gloves, and so forth—similar to now well-accepted reminders to fasten
seatbelts before driving.
Efforts are needed to identify and disseminate a set of best practices
for feedback, monitoring, and enforcement policies and mechanisms
regarding use of PPE. Challenges to be examined include developing
and disseminating effective supervisory and reporting procedures
that encourage feedback and fairly enforce adherence to infection pre-
vention practices.
Clarifying Relevant Work Practices
Much remains to be learned about specific issues related to wearing
PPE in the healthcare setting particularly during an influenza pandemic.
Research is needed to identify medical procedures and patient care proc-
esses (e.g., cleaning of patient rooms) that are particularly high risk for
influenza transmission. For aerosol-borne infections, those procedures
that generate mists and small droplets (e.g., nebulization, intubation,
bronchoscopy, laryngoscopy, upper gastrointestinal endoscopy, oral sur-

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INDIVIDUAL AND INSTITUTIONAL ISSUES
gery and dental procedures) have been of concern regarding transmission
of some respiratory diseases. During the SARS outbreak, these types of
procedures were associated with infection of healthcare workers (Fowler
et al., 2004; Loeb et al., 2004). Research should be conducted to deter-
mine if noninvasive positive-pressure ventilation (e.g., continuous posi-
tive airway pressure) increases the risk for influenza transmission to
healthcare workers. If proven to be relatively safe, these noninvasive
ventilatory modes would be highly desirable to improve surge capacity
when treating large numbers of patients with severe respiratory disease.
Additionally, research is needed regarding the most effective proce-
dures for donning and doffing PPE in caring for patients with influenza.
The potential for an ensemble approach to healthcare PPE should also be
explored. The piece-by-piece process by which PPE must be taken on
and off is more likely to result in self-contamination than the process by
which a powered air-purifying respirator and a double-layered suit are
donned and doffed (Zamora et al., 2006). PPE ensembles have not been
the norm for healthcare workers and could be explored as could refine-
ments to the proper sequencing of putting on or taking off PPE. Examin-
ing effective approaches may include the use of pictorial reminders at
every PPE station or a buddy system to assist and reinforce the proper
use of PPE.
Infection control practices, including appropriate PPE use, vary
widely among hospitals and other healthcare facilities, private offices,
and in-home care. A concerted effort to identify best practices in infec-
tion control and disseminate this information to other healthcare facilities
could increase worker and patient safety and have positive ramifications
well beyond preparedness for an influenza pandemic. Model hospital
wards or units with high numbers of patients on respiratory isolation
(e.g., TB wards, burn units) should be identified and their infection
control practices, including PPE protocols and training methods, should
be shared as should model practices in other healthcare settings. Identify-
ing best practices in infection control and worker safety will provide
the standards to be expected for units with similar patient mix during
a pandemic.
OPPORTUNITIES FOR ACTION
As discussed throughout this chapter, there are a number of areas to
be explored for promoting worker safety in healthcare facilities. In-

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138 PREPARING FOR AN INFLUENZA PANDEMIC
creased efforts are needed to identify and disseminate best practices,
conduct pilot studies, and conduct research.
Immediate Opportunities
Efforts to improve PPE compliance could have an immediate impact
(in the next 6 to 12 months) in improving the nation’s readiness for pan-
demic influenza (as well as protecting healthcare workers against other
infectious diseases or hazardous exposures).
• A commitment by healthcare employers to promoting, training,
and enforcing PPE compliance could increase adherence to PPE proto-
cols and foster the expectation and norm for appropriate PPE use.
• Efforts by the Joint Commission and state health departments to
emphasize PPE compliance in accreditation and other assessments could
focus attention on PPE issues and enhance adherence to PPE protocols.
Key Research Needs
Opportunities abound for improving worker safety and promoting
the culture of safety in healthcare facilities. Important areas for research
include
• Define and promote strategies to increase adherence to infection
control.
• How can the safety culture of healthcare facilities be improved?
What approaches best facilitate a healthcare organizational culture that
promotes safety?
• What are the best mechanisms to communicate with and receive
feedback from frontline healthcare workers in order to ensure that infec-
tion control measures are practical and feasible while still enhancing
safety?
• What are the best ways to train healthcare workers on appropri-
ate use of PPE? What is the feasibility of fit testing and “just-in-time”
training?
• How do worker safety and patient safety interact? How can pri-
orities be balanced where they conflict?
• Is a continued focus on procedure-driven PPE feasible?

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INDIVIDUAL AND INSTITUTIONAL ISSUES
• How can influenza patients best be identified early?
• What interventions prevent healthcare-acquired influenza?
SUMMARY AND RECOMMENDATIONS
Despite expert recommendations and high-risk conditions, healthcare
workers often do not wear PPE in situations that warrant its use, and PPE
compliance rates are low. Lack of time is frequently reported as the rea-
son for not adhering to PPE requirements, as is the perception that using
PPE interferes with the healthcare worker’s ability to perform his or her
job. Use of gloves appears to be more frequent than use of other types of
PPE, particularly respirators.
Improving worker safety necessitates an organization-wide dedica-
tion to the creation, implementation, and maintenance of safety
practices—a culture of safety. In order for a culture of safety to work
effectively, responsibility for both personal safety and the safety of oth-
ers must be a joint employer-employee responsibility. Key components
in promoting a culture of safety in healthcare facilities focus on provid-
ing leadership and commitment to worker safety, emphasizing education
and training, improving feedback and enforcement of PPE policies and
use, and clarifying work practices and policies. A concerted effort is
needed to identify best practices in infection control and disseminate this
information to all sites where health care is provided. These best prac-
tices could increase worker and patient safety and have positive ramifica-
tions well beyond preparedness for an influenza pandemic.
The committee has developed the following set of recommendations
aimed at improving the use of PPE by healthcare workers and developing
best practices.

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140 PREPARING FOR AN INFLUENZA PANDEMIC
Recommendation 6 Emphasize Appropriate PPE Use in Pa-
tient Care and in Healthcare Management, Accreditation, and
Training
Appropriate PPE use and healthcare worker safety should be
a priority for healthcare organizations and healthcare work-
ers, and in accreditation, regulatory policy, and training.
• Healthcare employers should strengthen their or-
ganization’s commitment to a culture of safety by
providing leadership in worker safety; instituting
comprehend-sive, state-of-the-art training and educa-
tion programs; facilitating easy access to PPE; giving
feedback to supervisors and employees on PPE ad-
herence; and enforcing disciplinary actions for non-
compliance.
• Healthcare workers should take responsibility for
their safety by working to enhance the culture of
safety in the workplace and by adhering to PPE pro-
tocols.
• Healthcare accrediting organizations (including the
Joint Commission and state health departments)
should set, implement, and enforce work standards in
hospitals and other healthcare facilities to ensure that
proper use of PPE is a priority and a sentinel event
subject to controls at the administrative, supervisory,
and individual levels.
• Healthcare accrediting and credentialing organiza-
tions should ensure that PPE training is part of the
accreditation and testing curricula of health profes-
sional schools of nursing, medicine, and allied health
and that PPE concepts and practice are included on
certification examinations and as continuing educa-
tion training requirements.
Recommendation 7 Identify and Disseminate Best Practices
for Improving PPE Compliance and Use
CDC and AHRQ should support and evaluate demonstration
projects on improving PPE compliance and use. This effort
would identify and disseminate relevant best practices that
are being used by hospitals and other healthcare facilities to

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INDIVIDUAL AND INSTITUTIONAL ISSUES
• Demonstrate, implement, evaluate, and improve the
integration of worker safety into the protocols and
practice of the organization.
• Develop, implement, and evaluate evidence-based
training programs on risk assessment and the use of
PPE, including addressing practical realities of wear-
ing PPE, donning and doffing, decontamination, and
waste disposal.
• Develop, implement, and evaluate worker safety
communication programs focusing on infection con-
trol, PPE, and reduction of risk and barriers during
an influenza pandemic.
• Monitor, enforce, and provide feedback to supervi-
sors and employees regarding appropriate use of
PPE.
• Evaluate and determine which practices are most ef-
fective regarding PPE use by healthcare workers, pa-
tients, and visitors, with a focus on respirator use.
Recommendation 8 Increase Research and Research Transla-
tion Efforts Relevant to PPE Compliance
NIOSH, the National Institutes of Health, AHRQ, and other
relevant agencies and organizations should support research
on improving the human factors and behavioral issues re-
lated to ease and effectiveness of PPE use for extended peri-
ods and in patient care-interactive work environments.
Translational research efforts should include a focus on
• identifying effective approaches to donning and
doffing PPE, including enhancements in PPE ensem-
ble design;
• developing standard-of-use protocols based on infec-
tion prevention and control policy with clear, simple-
to-use algorithms; and
• examining behavioral implementation strategies for
sustained use of PPE, including a focus on patient
and community education as well as healthcare pro-
vider education.

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